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The patient came to the clinic 21-November-2019 complaining inability to walk the last 3 years with weak four limbs, more the left and hypalgesia from the right C4 down. MRI of the cervical spine bad quality, not complete study performed 27-December-2017 showing intradural mass behind C1-2 23x14.7 mm in dimension with severe edema of the spinal cord down to C5.


On examination: there is weak both deltoids -4/5, right biceps 4/5, grip right hand 4/5, left hand 3/5, extensors both hands 3/5. both biceps 3/5. Weak dorsi and planterflexion right foot 3/5, left foot 2/5, both quadriceps femoris 4/5 and left iliopsoas muscles 2/5. There is analgesia below the right C4 dermatome. Deep reflexes S>D with Hoffmann more brisk in the right. Babinski positive right side and bilateral clonus more brisk in the left foot. Defecation and micturition preserved.


The patient was sent for investigations  with complete protocol of MRI with clinical applications, including fibertraking and spectroscopy, which were done 21-November-2019 showing huge meningioma occupying the intradural space 28x14.7 mm with matrix of the tumor anterior. Spectroscopy ruled out malignant nature denoting meningioma character of the lesion. 


In Concord position with the head maximally flexed down, trying to avoid CSF coming from the intracranial cavity, laminectomy of C1 and C2 was performed and the posterior rim of the foramen magnum was drilled out. The dura was opened and the edges reflected to the sides. Inspection around the spinal cord ruled out presence of meningioma or exophytic tumor. The tumor was seen through a very thin layer of the spinal cord of the right side of the spinal cord. Sharp dissection of the spinal cord over the tumor longitudinal to expose the tumor. Piece meal resection of the tumor and part was sent for histologic studies and using SONOCA 300, some parts of the tumor were resected. There is calcification inside the tumor, which were used as landmark for tumor resection. The NVM5 was used with MEP which showed after start of the surgery failure to record activity from the left side, which was actually not violated. Using MultiGen bipolar stimulation both sides were responding at the grid areas. The procedure was undertaken without using muscle relaxants and the patient could move the right side of the body. Strict hemostasis after ensuring total removal of the tumor. The patient was checked by MRI and no residual of the tumor was seen. Routine closure of the wound.


Smooth postoperative recovery. There is dense plegia of the left extremities. She was sent to the ICU.


Follow Up


The patient in the ICU at 19.00 after receiving 50 mg Pethidine, got loss of consciousness and blood gas was performed showing high level of CO2. The vital signs are acceptable and it was planned to keep monitoring. The morning of next day, chest X-ray showed cardiomegaly and patchy chest. Repeat MRI showed improvement of the surgical site with normal brain. Cardiologist confirmed presence of myxoma and the patient was put in ventilator to resolve the CO2 narcosis. After correction, the patient regained consciousness and was planned to keep her in ventilator for three days. 


A trail to put the patient with extubation was tried 29-December-2019, but the patient asked to put her back to ventilator after one hour. Tracheostomy size 8 was performed the morning of 30-December-2019.


At the morning of 03-January-2020 the patient progressed difficult breathing and at 13.00  the tracheostomy was inspected and it was half away out. Trail to reinsert it and replace it failed and surgical emphysema with severe bronchial spasm took place. Cardiac arrest and brain death was recorded at 13.30. 



This case is challenging with its severe compression of the spinal cord at C1-2 level with practical quadriparesis and left sided para-aneasthesia below right C4 dermatome.


It is mandatory to keep the patient under IOM at all stages of surgery, trying not to touch the severely compressed spinal cord. 


In this case the tumor turned to be an intramedullary tumor, for what the spinal cord was violated at its thinnest part to expose and remove of the tumor.


Logically speaking the tumor must be in the left side, but it turned to be located at the right.


In retrospective analysis the tumor bigger mass was compressing the right side of the upper part of the crossing of the pyramidal tract.


The histologic result was consistent with schwannoma.


This is the 192d case using MultiGen in the lateral aspects of the spinal cord, which confirmed presence of connectivity to both girdle muscles at stimulation around 1.2 V both sides.














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2019 NVM5 ® Intraoperative Neuromonitoring (IOM)

Fig.1: The mass and it relation with the spinal cord. Notice the fibers are still preserved in the left side of the mass.

Fig. 2. Central control of respiration. The pontine respiratory group, consisting of the pneumotaxic center and the apneustic center, provides tonic input to the medulla to control smooth respiratory rhythm. The apneustic center, which inhibited by the pneumotaxic center, delivers excitatory input to the pre-Bötzinger complex. Receiving sensory information from peripheral chemoreceptors and pulmonary mechanoreceptors, the dorsal respiratory group of the nucleus tractus solitarius controls inspiratory muscles through output via the phrenic nerves (emerging from the phrenic motor nuclei at the ventral horn of cervical spinal cord levels C3-C5) and external intercostal nerves. Much like the dorsal respiratory group, the rostral portion of the ventral respiratory group provides output to the inspiratory muscles. Conversely, the caudal portion of the ventral respiratory group provides output to the expiratory muscles via the internal intercostal nerves. With permission of Sardar Ali Khan.

Back Up!

Notice: Not all operative activities can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also escaped from the plan .
















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